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Social Security Disability Practice Center

If you are disabled and unable to work, you may be eligible for Social Security Disability benefits. For answers to your questions about Social Security Disability, contact our firm to schedule a consultation with an experienced attorney.

Helping You Obtain The Benefits You Deserve

The attorneys of Chermol & Fishman, LLC, in Philadelphia, Pennsylvania, have insider experience to put to work for you. If you have become disabled through an injury, disease or other medical condition, please contact us to discuss filing a Social Security disability (SSD) or supplemental security income (SSI) claim.

To learn more about Social Security benefits, please review the information below and visit our disability benefits page.

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Social Security Disability Contact Form

Personal Information

Full name

Maiden name

Other names used

E-mail address

Phone number

Business phone

Cell phone

Address

City

State

Zip

Please describe all of your injuries, illnesses, symptoms, and disabilities, whether physical, mental, or emotional.

How do your medical problems limit your daily activities?

Are you able to work?
Yes No

Are/were you self-employed?
Yes No

What is your age?

What is the last grade you completed in school?

Do you have a high school diploma or its equivalent?
Yes No

Do you attend a vocational school or college or program?
Yes No

If so, what did you study and did you earn any certifications or licenses?

Did you attend college?
Yes No

If so, what did you study and did you earn any degrees?

Please describe any graduate study or advanced or professional degrees.

Do you possess any vocational or professional licenses?

Approximately how long have you been in the workforce? (years)

Describe briefly the types of work you have performed.

If you are able to work, how many hours can you work per week?

Have you filed for disability benefits for the medical problem/s described above?
Yes No

Have you been turned down for benefit payments based on the medical problem/s described above?
Yes No

Have you appealed a Social Security decision that denied you benefits for the medical problem/s described above?
Yes No

Other information or concerns?

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